1 Chest X-ray 450521V201 CT scan Subclavian artery 450521V201 - - PDF document

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Case presentation

Paul De Leyn, MD, PhD Thoracic Surgery University Hospitals Leuven Belgium

Perspectives in Lung Cancer Brussels 6-7 march 2009 LEUVEN LUNG CANCER GROUP

• P. De Leyn,W. Coosemans, H. Decaluwé,
• Ph. Nafteux, D. Van Raemdonck, G. Decker, T. Lerut
• J. Vansteenkiste, K. Nackaerts, C. Dooms
• Y. Lievens

S . Stroobants

• W. Dewever

Department of Thoracic Surgery Department of Pneumology Department of Radiotherapy Department of Nuclear Medicine Department of Radiology

• 02-2003
• 57-year lady
• 3 months pain in left schoulder

and upper arm – Antiflogistics – Morfine

• Horner syndrome
• Medical history

– 20 packyears

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Chest X-ray

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CT scan

Subclavian artery

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Investigations

• Laboratory

– CEA : 12.2 μg/L (< 3,4 μg/L )

• Bronchoscopy : normal

– Aspirate : normal – Transbronchial biopsy : normal

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– Transthoracic puncture : large cell carcinoma

• Bone scintigraphy : normal
• PET scan : T positive, N0M0
• Pulmonary function test : normal

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Diagnosis

• Pancoast tumor
• cT4 (Horner, subclavian artery) N0M0

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THERAPY?

Further therapy?

• 1. Chemotherapy
• 2. Radiotherapy
• 3. Chemoradiotherapy
• 4. Induction radioTx + surgery
• 5. Induction chemoradioTx + surgery

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Superior sulcus tumours - Pancoast tumor

Major challenge : control of locoregional disease Low complete resectability rate despite major procedures Preoperative RT (30-35 Gy)

T3N0 : R0 : 66%, T4N0 : R0 : 18%, 5-year survival : 12%

Rush et al., J Thorac Cardiovasc Surg 2000;119:1147-1153

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Induction chemoradiotherapy for pancoast (SWOG 9416)

• Inclusion : cT3-T4NO (mediast : neg) n=110

C t h di th ( i t id 45 )

• Concurrent chemoradiotherapy (cis, etoposide; 45 gy)
• Surgery in responders and stable disease

Rusch et al. J Thorac Cardiovasc Surg, 2001;11:472-83 Rusch et al. J Clin Oncol 2007;25:313-318

Induction chemoradiotherapy for pancoast (SWOG 9416)

Rush et al. J Thorac Cardiovasc Surg, 2001;11:472-83 Rush et al. J Clin Oncol 2007;25:313-318

Induction chemoradiotherapy for pancoast (SWOG 9416)

• Complete resectability : 75%
• Pathological complete response or minimal

microscopic disease : 65% – Overall survival (5-yr) : 44% – Survival in R0 resections (5-yr) : 54%

Rusch et al. J Thorac Cardiovasc Surg, 2001;11:472-83 Rusch et al. J Clin Oncol 2007;25:313-318

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Induction chemoradiotherapy for pancoast (SWOG 9416)

54% (R0 resections)

Rusch et al. J Thorac Cardiovasc Surg, 2001;11:472-83 Rusch et al. J Clin Oncol 2007;25:313-318

• 20-02-2003 : Cervical mediastinoscopy

– Negative at levels 7, 4L, 4R and 2R

• Concommitant chemoradiotherapy (start 10-03-2003)

– Cisplatin-etoposide (2 courses) – 45 gy (25 fractions of 1.8 gy)

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45 gy (25 fractions of 1.8 gy)

• Reevaluation 18-04-2003

– No pain – CT : yT4N0M0

CT after induction chemoradioTx

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yT4N0M0

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CT after induction chemoradioTx

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yT4N0M0

Further therapy?

• 1. Surgery
• 2. Further radiotherapy
• 3. Stop therapy

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• 06-05-2003 : Left posterolateral thoracotomy

(Paulson incision)

• Upper lobectomy + chest wall resection (rib 1 +

2).

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No reconstruction of chest wall

• Pathology : fibrosis +++

Some small islands of viable tumor pT2N0M0, complete resection

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Giant cell Necrosis Sclerosis, macrophages Cholesterol

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Viable tumor cells Giant cell Sclerosis, macrophages, cholesterol

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CT scan is poor predictor of response

SWOG 9416 cT3-T4N0M0 pancoast tumors (n=110) Complete resectability : 75%

65% of specimens showed a pathologic complete

17 partial response on CT 15 stable disease on CT

response or minimal microscopic disease 32 (36%) pathologic complete response

Rusch et al. J Thorac Cardiovasc Surg, 2001;11:472-83 Rusch et al. J Clin Oncol 2007;25:313-318

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• No postoperative

problems (hospital stay : 11 days)

• 2 adjuvant courses of

cisplatinum-etoposide

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cisplatinum etoposide (start 26-05-2003)

• March 2008 : No

evidence of disease (CEA : 1,6 μg/L)

Materials and methods

• April 2002 – februari 2008
• 32 patients (prospective, consecutive)
• cT4 tumor (17) – Pancoast 15 (cT3-4)

cT4

P l t 5

Pancoast

• N0 – M0 (PET or CT/PET and mediastinoscopy)

Pulmonary artery : 5 Atrium : 5 Aorta : 3 Extens mediastinal infiltration : 2 Recurrent laryngeal nerve : 1 Subclavian artery : 1 cT3 : 5 cT4 : 10

De Leyn et al, J Thorac Oncol 2009;4:62-8 De Leyn et al, J Thorac Oncol 2009;4:62-8

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Postoperative morbidity/mortality

• Mean hospital stay : 9.2 days
• No hospital mortality
• ICU : 1 patient
• No bronchopleural fistulae or empyema

De Leyn et al, J Thorac Oncol 2009;4:62-8 De Leyn et al, J Thorac Oncol 2009;4:62-8

86% 60%

De Leyn et al, J Thorac Oncol 2009;4:62-8

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Remaining questions

• Improve induction therapy?

– Increase radiation dose – Hyperfractionated accelerated RT – Third-generation chemotherapy? g py

• Profyllactic cranial irradiation?

High dose radiotherapy in trimodality treatment of pancoast tumors N = 36 Preoperative chemoradiation (mean total radiation dose : 56.9 gy)

Kwong et al, J Thorac Cardiovasc Surg 2005;129:1250-7

dose : 56.9 gy) R0 resection : 97% Pathological CR : 40% Operative mortality : 2.7%

Prohyllactic Cranial irradiation?

Single site brain metastasis is most common site of recurrence (>40%) Significant reduction in incidence of brain metastasis

Rusch et al. J Clin Oncol 2007;25:313-318 Kwong et al, J Thorac Cardiovasc Surg 2005;129:1250-7 Pöttgen et al., J Clin Oncol 2007;25:4987-92

in patients with operable stage-IIIA NSCLC undergoing trimodal treatment

Control : 35% PCI : 7.8%

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Conclusion

• Trimodality treatment is feasible with low

morbidity and mortality

• High complete resectablity
• CT scan is poor predictor of response. Both

patients with response or stable disease on CT should be explored

• Prophyllactic PCI?
• Multidisciplinary approach

K.U. Leuven, Belgium University Hospital Gasthuisberg Leuven Lung Cancer Group (www.LLCG.be)